Senior Care Options (SCO) Plans

(A) Enrollment Requirements. In order to voluntarily enroll in a SCO Plan, a MassHealth Standard member must meet all the following criteria: (1) be 65 years of age or older; (2) be eligible for MassHealth Standard as defined in 130 CMR 519.001(B)(1); (3) be enrolled in Medicare Parts A and B, be eligible for Medicare Part D, and have no other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001; (4) live in a designated service area of a SCO Plan; and (5) not be subject to any of the exclusions defined in 130 CMR 508.002(B). (B) Selection Procedure. The MassHealth agency will notify members of the availability of a SCO Plan in their service area and of the procedures for enrollment. An eligible member may voluntarily enroll in any SCO Plan in the member’s service area. A service area is the specific geographical area of Massachusetts in which a SCO Plan agrees to serve its contract with the MassHealth agency and the Centers for Medicare & Medicaid Services. Service area listings may be obtained from the MassHealth agency or its designee. The list of SCO Plans that the MassHealth agency will make available to members will include those SCO Plans that contract with the MassHealth agency and provide services within the member’s service area. (C) Obtaining Services When Enrolled in a SCO Plan. When a member chooses to enroll in a SCO Plan in accordance with the requirements under 130 CMR 508.008, the SCO Plan will deliver the member’s primary care and will authorize, arrange, integrate, and coordinate the provision of all covered services for the member. Upon enrollment, each SCO Plan is required to provide evidence of its coverage, including a complete list of participating providers, the range of available covered services, what to do for emergency conditions and urgent care needs, and how to obtain access to covered services such as specialty, behavioral health, and long-term-care services. (D) Disenrollment from a SCO Plan. Disenrollment requests will be effective the first day of the month following the month the request is received by the MassHealth agency or its designee. (E) Discharge or Transfer. The MassHealth agency may discharge or transfer a member from a SCO Plan for good cause, including but not limited to cases where the SCO Plan demonstrates to the MassHealth agency’s satisfaction a pattern of noncompliant or disruptive behavior by the member. In each case, notice to the member of the discharge or transfer will state the justification for the discharge or transfer. (F) Other Programs. A member may not be enrolled in a SCO Plan and concurrently participate or be enrolled in any of the following programs or plans: (1) programs described at 130 CMR 519.007: Individuals Who Would Be Institutionalized; except the Home- and Community-based Services Waiver–Frail Elder described in 130 CMR 519.007(B): Home- and Community-based Services Waiver–Frail Elder; (2) Medicare demonstration program or Medicare Advantage plan, except for a Medicare Advantage Special Needs Plan for Dual Eligibles contracted as a SCO Plan; (3) any Medicare Demonstrations wherein concurrent participation in a SCO Plan is prohibited; (4) Employer Group Waiver Plans or other employer-sponsored plans; or (5) plans receiving a retiree drug subsidy. (G) Copayments. Members who are enrolled in a SCO Plan must make copayments in accordance with the SCO’s MassHealth copayment policy. Those SCO Plan copayment policies must (1) be approved by MassHealth; and (2) be consistent with applicable copayment requirements set forth in 130 CMR 450.000, 130 CMR 506.000, and 130 CMR 520.000.